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Policy on Disruptive Social BehaviourPDF 23
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Annexe 2: Standard Reporting Form (SRF)
Date: _________________________
You can fill out this form to tell school staff about a hurtful encounter you would like to report.
About You
Please include your name and other details since it will help us look into the problem.
Name: ______________________________________________ Student #: _________________________
Class & section: ______________________________________
I am (choose one): Student/ Parent/Guardian/ Staff Member/ Other: ___________________________________
Tell Us What Happened
Student(s) Harmed
If you are self-reporting, write “self” under the subsection “student(s) harmed”. If you are reporting on
someone’s behalf, please provide us with as much information about the harmed student as possible.
1. Name: ____________________________________
Class & section: ______________________
Student #: _________________________________
2. Name: ____________________________________
Class & section: ______________________
Student #: _________________________________
Student(s) Who Did Harm
1. Name: ____________________________________
Class & section: ______________________
Student #: ___________________________________
2. Name: ____________________________________
Class & section: ______________________
Student #: ___________________________________
3. Name: ____________________________________
Class & section: ______________________
Student #: ___________________________________
Details of the incident
When did it happen (if you don’t know the exact time, tell us what time you think it happened):
Day & date: _________________________________
Time: ____________________________________
Where did it happen (be as specific as possible):
__________________________________________________________________________________________
Policy on Disruptive Social Behaviours, Aitchison College
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